Which describes the prescription adjudication process?

• A. The prescription is approved automatically
• B. The script arrives, entered into computer, submitted; if issues exist with copay, adjudication may reject
• C. The patient must contact the prescriber before adjudication
• D. The script is never submitted to the payer

Answer: (B)

Adjudication is the step where a pharmacy claim is evaluated by the payer to determine payment based on the patient’s benefits. In practice, after the prescription is filled, the pharmacist enters the prescription into the computer and submits the claim to the payer. The payer then checks the patient’s coverage, formulary status, benefit details, and the copay. If there’s a mismatch or issue with the copay (or other eligibility details), the adjudication may reject the claim, prompting correction or a different payment arrangement before any reimbursement is issued. This flow—entering the script, submitting the claim, and the payer deciding based on coverage and copay—best describes the prescription adjudication process.

Automatic approval ignores necessary verification, and claims aren’t guaranteed to be paid without checks. The claim is not typically kept from submission to the payer, and the patient doesn’t usually need to contact the prescriber before adjudication—the process occurs between the pharmacy and the payer, with the patient’s role mainly in providing accurate information and making any required payments.